Humanities - Canadian Medical Association Journal · Madhouse: A Tragic Tale of Megalomania and...
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DOI:10.1503/cmaj.081783 DOI:10.1503/cmaj.081925 Madhouse: A Tragic Tale of Megalomania and Modern Medicine Andrew Scull Yale University Press; 2005. 360 pp, US$18.00 E nthusiasts of psychiatric treat- ments have sometimes been ac- cused of using attractive theories to shroud weak bodies of evidence. But when Dr. Henry Cotton, chief psychia- trist at the Trent State Mental Hospital in New Jersey from 1916 to 1933 relied on “focal sepsis” to justify his extreme treat- ments, a weak theory was used to cover one of the 20th century’s major scandals. The idea that hidden infection could cause madness had its roots in folk be- liefs about auto-intoxication and seemed plausible to the public and to physicians who were eager to help the mentally ill. Cotton claimed that new develop- ments in bacteriology allowed him to identify infected patients (potential treatment responders), while modern surgery offered a definitive solution. Despite initial opposition, he moved forward with a campaign of aggressive diagnosis and surgery on hundreds of patients, removing teeth, tonsils, and sometimes sexual organs and colons (not necessarily in that order or re- stricted to a single procedure). Cotton reported an 85% cure rate for insanity in the 1920s, when his more circumspect colleagues could only wish for similar results. Few sounded the alarm when his outcomes were not replicated at other centres, and more than a decade went by before it was widely learned that Cotton’s success rested on an unre- ported 30% mortality rate and an unre- alistically broad definition of cure. Andrew Scull’s book shows how a theory-based intervention was promoted to the popular press, hospital administra- tors and politicians, all hoping for a fast, cost-effective solution to mental illness. He also illustrates how the needs of soci- ety’s most vulnerable members were trumped by personal ambitions and pro- fessional loyalties reaching to the highest levels of American medicine, allowing the suppression of key scientific evi- dence for more than 10 years. While some might argue that the case of Henry Cotton is a tragic, but isolated event, others may wonder why similar social forces appear to coalesce from time to time, catalyzing unfortunate situ- ations and obscuring the basic ideals of the medical profession. Just as the hor- rors of Trent State in the 1920s and 1930s were winding down, the lobotomy craze, another tale of surgical enthusiasm with a charismatic self-promoter acting on a poorly tested theory, was beginning. Is the social organization of medicine partly to blame for malpractice? Will our current regulatory system protect us from interventions based on hope-infused the- ories rather than solid evidence? As one line of social enquiry into this complex problem, medical history appears to have more to offer than curiosities from the past. In the words of the great British his- torian William Stubbs, “the roots of the present lie deep in the past, and nothing in the past is dead to the man who learns how the present comes to be.” Dorian Deshauer MD Associate Editor, Practice CMAJ An anatomy of malpractice Review Humanities CMAJ • MAY 26, 2009 • 180(11) © 2009 Canadian Medical Association or its licensors 1139 Metaphors are easy. What it isn’t: no fingertip sworls, so the police aren’t interested; no long lines or abrupt breaks like palm-reading; no fuzzy snowstorm screen like a crystal ball; no crazy QRS dowsing. No one can even tell that the heart is beating: the lights may be on, that’s all. You need a pulse for that. You need more than chicken scratch, and what of the exploring heart, the intrepid muscle with a wandering baseline? No habla anglais. Ne parle pas. What it is: a detective story. The private dicks are part of it. There is a gravedigger shovelling the Q wave’s six feet, the long plot of a pause. It is a history: grizzled, from a Grizzly Adams. But in the end it is an ocean, an ocean of waveforms, an ocean that stretches across the basin of a life. Each feeler P, P of reconnaissance, P of preceding, leads to the enormous yes of a don’t-give-me-a complex, then the billowing blanket of a ST segment sloping up or down depending on bed angle. Bedside, I peer at the tracing and think lifestyle modification, lifestyle modification, what every heart needs is the amplitude of truth. But I’m not looking for truth. I’m looking for closed-mouth moments and the wave of goodbye, goodbye, which the police would be interested in, there is an order to stay within the city, but it is unenforceable. Shane Neilson MD Family physician Guelph, Ontario Reading electrocardiograms Yale University Press
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Madhouse: A Tragic Tale of Megalomaniaand Modern Medicine
Andrew ScullYale University Press; 2005.360 pp, US$18.00
Enthusiasts of psychiatric treat-ments have sometimes been ac-cused of using attractive theories
to shroud weak bodies of evidence. Butwhen Dr. Henry Cotton, chief psychia-trist at the Trent State Mental Hospital inNew Jersey from 1916 to 1933 relied on“focal sepsis” to justify his extreme treat-ments, a weak theory was used to coverone of the 20th century’s major scandals.
The idea that hidden infection couldcause madness had its roots in folk be-liefs about auto-intoxication and seemedplausible to the public and to physicianswho were eager to help the mentally ill.
Cotton claimed that new develop-ments in bacteriology allowed him toidentify infected patients (potentialtreatment responders), while modernsurgery offered a definitive solution.Despite initial opposition, he movedforward with a campaign of aggressivediagnosis and surgery on hundreds ofpatients, removing teeth, tonsils, andsometimes sexual organs and colons(not necessarily in that order or re-stricted to a single procedure). Cottonreported an 85% cure rate for insanity inthe 1920s, when his more circumspectcolleagues could only wish for similarresults. Few sounded the alarm whenhis outcomes were not replicated atother centres, and more than a decadewent by before it was widely learnedthat Cotton’s success rested on an unre-ported 30% mortality rate and an unre-alistically broad definition of cure.
Andrew Scull’s book shows how atheory-based intervention was promotedto the popular press, hospital administra-tors and politicians, all hoping for a fast,cost-effective solution to mental illness.He also illustrates how the needs of soci-ety’s most vulnerable members weretrumped by personal ambitions and pro-fessional loyalties reaching to the highest
levels of American medicine, allowingthe suppression of key scientific evi-dence for more than 10 years.
While some might argue that the caseof Henry Cotton is a tragic, but isolatedevent, others may wonder why similarsocial forces appear to coalesce fromtime to time, catalyzing unfortunate situ-ations and obscuring the basic ideals ofthe medical profession. Just as the hor-rors of Trent State in the 1920s and1930s were winding down, the lobotomycraze, another tale of surgical enthusiasmwith a charismatic self-promoter actingon a poorly tested theory, was beginning.Is the social organization of medicinepartly to blame for malpractice? Will ourcurrent regulatory system protect us frominterventions based on hope-infused the-ories rather than solid evidence? As oneline of social enquiry into this complexproblem, medical history appears to havemore to offer than curiosities from thepast. In the words of the great British his-torian William Stubbs, “the roots of thepresent lie deep in the past, and nothingin the past is dead to the man who learnshow the present comes to be.”
Dorian Deshauer MDAssociate Editor, PracticeCMAJ
An anatomy of malpractice
Review
Humanities
CMAJ • MAY 26, 2009 • 180(11)© 2009 Canadian Medical Association or its licensors
1139
Metaphors are easy. What it isn’t:no fingertip sworls, so the policearen’t interested;
no long lines or abrupt breakslike palm-reading;
no fuzzy snowstorm screen like acrystal ball;
no crazy QRS dowsing. No onecan even tell
that the heart is beating: thelights may be on,
that’s all. You need a pulse for that. You need more
than chicken scratch, and whatof the exploring heart,
the intrepid muscle with a wandering baseline?
No habla anglais. Ne parle pas.
What it is: a detective story.The private dicks are part of it.There is a gravedigger
shovelling the Q wave’s six feet,the long plot of a pause.
It is a history: grizzled, from aGrizzly Adams.
But in the end it is an ocean, anocean of waveforms,
an ocean that stretches acrossthe basin of a life.
Each feeler P, P of reconnaissance, P of preceding,
leads to the enormous yes of adon’t-give-me-a complex,
then the billowing blanket of aST segment
sloping up or down dependingon bed angle.
Bedside, I peer at the tracing
and think lifestyle modification,lifestyle modification, whatevery heart needs
is the amplitude of truth. But I’mnot looking for truth.
I’m looking for closed-mouthmoments and the wave
of goodbye, goodbye, which thepolice would be interested in,
there is an order to stay withinthe city,
but it is unenforceable.
Shane Neilson MDFamily physicianGuelph, Ontario
Readingelectrocardiograms
Yal
e U
niv
ersi
ty P
ress
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